| NPI | 1275717597 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NY 033860) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: NY 033860) |
| Enumeration Date | 2007-12-21 |
| Last Update Date | 2019-06-10 |